Elbow Flashcards
Bony Articulations of the elbow
1) Ulnohumeral j.
2) Radiohumeral j.
3) Proximal Radioulnar j.
Elbow Stability
- Bony stabilisation of the olecranon/coronoid process & radial head is most important at end range F/E
- Collateral complex = static joint stability at mid-range
- Primary: Ulnotrochlear articulation, MCL/UCL (ANT) and LCL complex
- Dynamic: Brachialis, Anconeus, Biceps/Triceps, FCU
- In 90 elbow flexion, valgus stability relies on
- In full extension, stability is reliant
- UCL
- all structures
Describe Axial Load transfer through the elbow
- Classically60% of load is through radiohumeral j.
& 40% the ulnohumeral j. - Valgus: Majority of force is through radius
- Full EXT & SUP: Radio-capitellar j. gets more load
- PRO the ulnotrochlear
Elbow Terrible Triad
- Elbow dislocation
- Radial head fracture
- Coronoid fracture
Biomechanical Implications of the elbow for throwing sports and gymnastics
- the elbow is in 30-90 flexion in early acceleration phase, and is simultaneously subjected to large valgus load
- Gymnastics often weight bear in overhead position, with maximum elbow extension and an almost purely axially directed force.
Distal Bicipital tendon rupture MOI and risk factors
Uncommon, typically follows eccentric injury in dominant arm
RF:
- Over 30 M>F Smokers, steroid use
- 30% loss of elbow flexion and 40% strength in supination
Distal Bicipital tendon rupture S&S
- Pop, swelling, ecchymosis, shorten biceps with palpable pop eye deformity are often present
- Loss of active/passive extension
- Palpable gap
- Ve+ Hook Test
Distal Bicipital tendon chronic rupture
- Weeks to months the tenon retract proximally, lose elasticity and become atrophied
- The natural tunnel space filled with fibrous tissue
- Lateral antebrachial cutaneous n. could be scarred to the muscle belly, needing more formal dissection which may cause nerve dysfunction
Describe the functions of the Ulna collateral ligament, [Anterior and posterior BB, and transverse]
- Anterior BB:
Taut in all; mainly to valgus stability from 0-90 - Posterior BB:
Tense in elbow flexion; restrain to valgus beyond 120
Capsule thickening and secondary valgus stabiliser beyond - Transverse B:
insignificant stability to joint
Elbow Dislocation
MOI
- Falling on outstretched supinated hand (backward fall)
- Posterior is most common
- Anterior dislocation occurs more with extreme hyperextension (common with younger population)
Associated fractures with elbow dislocation
- Radial head,
- Coronoid process,
- Epicondyles
Posterolateral Rotatory Instability MOI
- FOOSH with forearm supinated + forceful valgus force
- 2nd to steroid injections for lateral epicondylitis or surgery
Posterolateral Rotatory Instability
- Most common
- Results in posterior radial subluxation or dislocation
- Involves LCL complex
Elbow Instability Stage 1
- LUCL disrupted, possible RCL and posterolateral capsule
- Sprain
- Posterolateral rotatory subluxation
Presentation
- Persistent symptoms of recurrent snapping
- Ve+ drawer
- Ve- lateral pivot shift sign
Elbow Instability Stage 2
Description
- A/P capsule disrupted + LCL complex
- Incomplete dislocation involving subluxation
Presentation
* Ve+ lateral pivot shift sign + Drawer
* Varus instability
* Stable to valgus stress after reduction 20 intact AMCL
Elbow Instability Stage 3
Description
* a. Disrupted posterior MCL, Posterior dislocation with axial compression
* b. Complete disruption of MUCL and AMCL
Presentation
* a. Not common clinically
* b. Seen commonly after dislocations
Clinical presentation and evaluation of elbow instability
- Lateral elbow pain [esp. in elbow extension and supination] from pushing up on armrest
- Common painful clicking, snapping, clunking or locking which occur in the extension and supination arc’s of motion.
- May have normal appearing elbow when atraumatic
- Pain difficult to elicit in chronic
- Provocative tests are important
Physical examination of instability with acute and chronic cases
Acute cases
- Pain prevents performing tests; will need to be done under anaesthesia
- Awake patients will have apprehension, which is regarded as Ve+ sig
Chronic cases
- examination may be unremarkable except for Ve+ pivot or Drawer
- ROM usually WNL and valgus/varus are not provocative
DDx for instability of elbow
- PLRI will often be misdiagnosed as a simple sprain
- Lateral Epicondylitis : when it doesn’t respond to conservative care, it’s often an underlying LUCL injury
- Radial Tunnel Syndrome : Deep elbow pain over posteroradial forearm
- Valgus Instability : pain on medial side, esp. during activity
- Pure proximal radial head dislocation : often encountered in children
Functional tests for elbow instability
- Table top relocation
- Floor up push up
- Chair sign
Managment for elbow instability
- Simple dislocation are mostly dealt with conservatively: splint forearm in supination to maximise stability
- Gradual ROM exercises [torn LUCL heal, restoring stability]
- Chronic: surgical management
Medial Instability MOI
- MCL is susceptible to injury when the extended and supinated elbow is forced into excessive valgus.
- FOOSH
- Non-weight bearing: Pitchers; late cocking and acceleration phase where the valgus-producing torque is at its greatest
Medial instability may be associated with?
- compressive fractures of the humeroradial j.
- Ulnar n neuropathy
- pronator flexor wrist complex injury
- excessive extension secondary to damaged anterior capsule
Physical examination and testing of meidal instability
- Tenderness over UCL
- Tender over posteromedial olecranon
- Crepitus
- Pain with forced extension
- Flexion contracture (loss of terminal elbow extension)
Testing:
* Valgus at 30 , 60 and 90 > valgus extension overload test
* Moving valgus, > milking manoeuvre,
Orthopaedic tests for medial instability
- Valgus/Varus Elbow Stress Test
- Moving Valgus Test
- Chair push-up test
- Posterolateral rotatory instability test (lateral pivot shift test)
- Posterolateral rotary drawer test
- Table-top relocation test
- Valgus extension overload test
Managment for Medial instability
- Conservative is tailored after assessment of techniques/condition, symptom duration, pain location, presence of any ulna n symptoms, and changes in capacity/performance.
- Conservative will include stopping aggravation activity, and gradually reintroduce it after the pain subsides while adjusting for technical errors.
- Proper conditioning of core muscles, scapular stabilisers and flexor-pronator muscles is crucial for appropriate management
- An acute instability in overload athlete wont suite conservative management
Oseochondral Lesion Aeitology
- Receptive micro trauma/ ischemia
- Genetics
- Acute trauma and ossification abnormalities
Excessive loading or excessive valgus (handball, water polo, weight lifting, tennis, gymnastics)
Classification of osteochondral lesions
- Juvenile (open growth plate): better prognosis/spontaneous heeling after conservative care
- Adult (closed growth plate)
- Further classified according to surface involved
Clinical presentation of osteochondral lesions
- Typical overhead athletes, young male (12-14), worsening of activity related pain and stiffness
- Late stage: Occasional mechanical symptoms which is concern for loose bodies
- Tenderness over Radiocapitellar joint and may lack some extension
- Crepitus esp. in supination and pronation
- Capitellar Shear Test – Valgus stress while moving, pain around 45
Treatment for osteochondral lesion
- No displacement and lesion is stable = conservative
[Activity modification, Bracing, Physical therapy] - Uncomplicated cases will return to normal activity in 3-4 months
- Major of cases usually heal
- Unstable cases over grade III = surgical
OCD and Panners differentiation
- Involves capitulum
- Self-limited condition
- Primarily affects boys < 10
- No Hx of trauma or repetitive valgus stress
- Radiographs show fissures, lucencies, fragmentation and contour change
Other DDx for OCD not including panners
- RA
- Insertional apophysitis [pre-pubescent patients]
- Septic Arthritis
- RA
- Epicondylar avulsion fractures [older]
- OA
Categories of nerve injury
1) Neurapraxia: least severe, local damage to myelin fibres, limited course
2) Axonotmesis: More severe, involves axon, can regenerate>takes months, recovery is usually incomplete
3) Neurotmesis: Complete disruption of axon, regrowth unlikely
MOI for nerve injury
- Direct pressure
- Repetitive microtrauma
- Stretch or compression-induced ischemia
What is Median N. Pronator Tere’s Syndrome
Entrapment of nerve between the 2 heads of the pronator teres. Commonly encountered in archers, pitches, tennis players and body builders often presents with CTS
S&S of Median N. Pronator Tere’s Syndrome
- Aching pain proximal volar forearm
- motor weakness and sensory deficit usually minimal [if present paraesthesia in thumb, index, middle, and radial half of ring finger typically numbness and sensory loss over the thenar eminence]
- Negative Tinel and Phalen tests
- No nocturnal component (as CTS)
Assessent for median n syndrome
- Direct Palpation of pronator teres in supinated forearm produces paraesthesia within one minute
- Neurodiagnostic studies unreliable
- Nerve function test [motor and sensory [thenar eminence]]
- Recovery with conservative care; Rest, NSAIDS, therapy, activity modification, splint
- Pronator test
Define Radial Tunnel Syndrome
- Involves the Radial N.
- Associated with compression, commonly by supinator canal
- Low annual incidence
S&S of Radial Tunnel Syndrome
- pain centrally in the forearm
- night pain
- pain is like lateral epicondylitis (location is 5cm distal)
RTS vs Tennis elbow - maximal tenderness
- RTS: Over anterior radial neck
- Tennis: Over ECRB
Define Posterior Interosseous Nerve neuropathy
- Motor deficit only , no pain
- Supplies all extrinsic except ECRL
- Dropped fingers and lack of thumb extension
Provocative tests for the Posterior Interosseous Nerve
- Resisted long finger extension: pain at radial tunnel weakness from pain
- Resisted supination test: Elbow and wrist extended “ ”
- Passive pronation with wrist flexion : pain in radial tunnel; stretch increases pressure in the tunnel
Ulnar N. Cubital Tunnel Syndrome - Paitents at risk
- Diabetes, obesity
- Occupation involving repetitive elbow F/E
- Prevalence increases with workers using repetitive movement, floor cleaners and those using vibrating tool
Ulnar N. Cubital Tunnel Syndrome causes/aeitiology
Prolonged elbow flexion or pressure directly on the elbow
Arthritis [bony spurs [OA] or swelling]
Ulnar N. Cubital Tunnel Syndrome - clinical presentation
- Ache in medial elbow, but most are n. symptoms
- Prominent feature is Loss of grip strength
- May have paraesthesia in fingers: exacerbated by elbow flexion and repetitive related activities
- When present:
- weak digit/thumb abduction
- weak thumb index finger punch
- night pain present with sleeping in elbow flexion
Ulnar N. Cubital Tunnel Syndrome - orthopaedic evaluation
- Elbow Tinel’s sign > Pronator Tere’s test [median]
- Elbow flexion test > Pinch grip test [median]
Pressure provocative test -> Froment sign
Elbow Tendinopathy risk factors
- overuse/repetitive microtrauma an athletic individuals
- other tendinopathy/tenosynovitis
- eccentric contraction
- Caucasian
- smoking/obesity/diabetes
- female, aged 45-54y
- oral steroid use
- Repetitive tasks involving flexion/pronation or extension/supination
Etiological factors for elbow tendinopathy
Degenerative mechanism leading to calcification, fibrosis, vascular proliferation and hyaline degeneration of the affected muscles without inflammation infiltration associated with a failed reparative process.
Newer treatment process for elbow tendinopathy
Treatment process have switched toward therapy aimed at tendon regeneration
- PRP: growth and repairs
- Collagen producing tenocyte-like cells
- Stem cells
DDx for elbow tendinopathy
- Arthritis
- RC tendinopathy
- Collateral ligament injury
- Radial n. compression
- Ulnar neuropathy
- Cervical radiculopathy
- CTS
- Myofascial referred pain
Lateral Epicondylitis - Clinical Features – History
Lateral Epicondylitis - Clinical History
- Insidious or sudden onset [unusal activities]
-Lateral elbow pain; often radiates into forearm - Weak grasp
-Hx of repetitive loading/gripping
Lateral Epicondylitis - Physical Clinical features
- Tenderness at origin of ECRB (majority)
- Insertional vs mid-substance lesions differ by site of maximal tenderness, latter being approx. 1-2cm distal to the lateral epicondyle
- Extensor digitorum [marudley test]
- Pain = wrist extensor stretching [passive flexion/mills test]
- Pain resisted wrist extension/forearm in pronation [Cozen’s test]
Lateral Epicondylitis - risk factors
- Repetitive overuse
- Occupation settings [elbow F/E over 2hrs per day, overloading tendons connecting epicondyle, overexposure to vibrating tools] |
Lateral Epicondylitis - DDX
- Radial tunnel syndrome compression of the posterior interosseous n. and its diagnosis is essentially clinical [electromyography often produces normal results]
- Cervicobrachial
- RC injuries
Lateral Epicondylitis - orthopaedic tests
- Cozen’s test
- Mill’s test
- Maudsley’s test
Lateral Epicondylitis treatment
- No treatment is universally accepted
- Therapeutic goals such as controlling pain, preserving movement, improving grip strength/endurance, restoring normal function, and preventing deterioration are recommended.
- Conservative management is preferred pathway
Describe how microscopic tears and scarring leading to tendon rupture and calcfication with tennis
- Over use, or poor techniques, or heavy racquets and or poor fitted grip
- Excessive load on tendon
- Dengenerative processess leading to
++ Plus continued use
Angiofibroblastic dysplasia encompasses
- Fibroblastic hypertrophy
- Disorganised collagen
- Vascular hyperplasia
Clinical classification for self limited care for lateral epicondylitis
- Phase 1: mild pain, resolves in 24 hrs
- Phase 2: Mild pain more than 48, no pain with activity, relieved with warm up
- Phase 3: Mild pain durng activity, no negative impact on activity, partially relieved with warm up
- Phase 4: Mild pain accompanied with ADL’s and negative impact of activty
- Phase 5: Harmful pain unrelated to activity, negative impact, does not prevent ADL’s, Rest to control pain
- Phase 6: Persistant, despite rest, prevent ADL
- Phase 7: Consistant pain at rest, aggravated after activity and disturbs sleep
Medial Epicondylitis Aeitology and risk factors
- repetitive strain frequent loaded gripping, forearm pronation, and wrist flexion
- throwing athletes
- golfers, tennis plays, baseball pitches
- valgus movement
- carpenters, utility workers, butchers, and caterers
RF: Smoking, diabetes, obesity, tasks with repetitive wrist flexion or forearm pronation for at least two hours/day
Medial Epicondylitis History/Physical examination
- Hobbies and work-related elbow movement investigated
-gradual or acute onset of pain, may be local or radiating into forearm or wrist - medial epicondylar pain, worse with resisted wrist flexion and passive wrist extension
- pain with tight grip/ a weak grip present in chronic
- Numbness involving ulnar n.
- pain generally notable 5-10mm distal to epicondyle
- aggravated with wrist flexion and pronation
Medial Epicondylitis DDx
- Ulnar neuropathy*
- OCD
- Ulnar or medial collateral ligament sprain*
- Myofascial pain complex
- Cervical radiculopathy*
- OA
- Elbow bursitis ……
- ++ more
Medial Epicondylitis imaging
- imaging is not really necessary, but helpful to rule out other pathology
- calcification of flexion-pronator tendon or traction osteophytes
- growth plate involvement should be excluded in younger patients as acute injuries will implicate the latter instead of the tendon
Medial Epicondylitis - prognosis
- overall is favourable with adequate management
- refractory conditions may resort to more aggressive approaches [surgery, injections, etc]
Medial Epicondylitis management
Same as lateral epicondylitis, either self limited, conservative or surgery depending on severity of presentation
Medial Epicondylitis orthopaedic
Reverse Mill’s
Pedi ASES – Outcome measure
Part 1 not scored.
Part 2: out of 18; high score = less symptoms
Part 3: Out of 48; high score = better function
Part 4/5 Out of 9 = high score = better function
Upper extremity functional Index -
Out of 80
Low score = increased difficulty with activity
